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V0 107 L, 10 <br /> UNIFIED PROGRAM CONSOLIDATED FORM ` <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (One page per site) Page 1 of 7 <br /> TYPE OF ACTION ❑1.NEW PERMIT ❑3.RENEWAL PERMIT ®S.CHANGE OF INFORMATION ❑7.PERMANENTLY CLOSED SITE Ore. <br /> (Check one itemonly) ❑4.AMENDED PERMIT(Specify change) ❑8.TANK REMOVED <br /> ❑6.TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION <br /> BUSINESS NAMB(aaa u FAULTY NAME a DBA-Ixdng animus Au 3. 1 FACILITY <br /> Rai Gas Station Inc.dba March Lane 76 IDNIA 1 <br /> NEAREST CROSS STREET al. FACILITY OWNER TYPE Lj 4.LOCAL AGENCY/DISTRICF4 <br /> West Lane and East March Lane ® 1.CORPORATION ❑5.COUNTY AGENCY- <br /> BUSINESS EI 1.GAS STATION 3.FARM S.COMMERCIAL 4m. ❑2.INDIVIDUAL ❑6.STATE AGENCY- <br /> TYPE ❑2.DISTR03UTOR ❑4.PROCESSOR ❑6.OTHER ❑3.PARTNERSHIP ❑7.FEDERAL AGENCY- <br /> TOTAL NUMBER OF TANKS 40a. Is facility on Indian Reservation 405. •If owner of UST is a public agency:name of mpervlew of division,section or 406. <br /> REMAINING AT SITE or trust lends? offce which operates the UST.(This is the conta t person for the rank rxoW&) <br /> 3 ❑Yes ®No <br /> I1. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 401. PHONE ere. <br /> Petros Rai Stations,LLC (209)478-6487 <br /> MARLING OR STREET ADDRESS em. <br /> 10944 FlamingStar Lane <br /> CITY 410. STATE 4U. ZIPCODE 412. <br /> Stockton CA 95209 <br /> PROPERTY OWNER TYPE 1.CORPORATION 2.INDIVIDUAL 4.LOCAL AGENCY/DISTRICT 6.STATE AGENCY 4U. <br /> ❑3.PARTNERSHIP ❑S.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> Petros Rai Stations,LLC (209)478-6487 <br /> MAILING OR STREET ADDRESS els. <br /> 10944 Flaming Star Lane <br /> j CITY 417. STATE 418. ZIP CODE 419. <br /> Stockton I CA 95209 <br /> TANK OWNER TYPE 0 I.CORPORATION 2.INDIVIDUAL U 4.LOCAL AGENCY/DISTRICT 6.STATE AGENCY em. <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY K HQ 44 Call 916)322-9669 if questions arise 421. <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) ❑I.SELF-INSURED ❑4.SURETY BOND ❑7.STATE FUND ❑10.LOCAL GOVT MECHANISM en. <br /> ❑2.GUARANTEE ❑5.LETTER OF CREDIT J®&STATE FUND&CFO LETTER ❑99.OTHER: <br /> ❑3.INSURANCE ❑6.EXEMPnON ❑9.STATE FUND&CD <br /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check one box to indicate which address should he used for legal notifications and mailing. <br /> Le01 notifications and mailings will he sent to the tads owner unlen box 1 or 2 is checked. ❑ 1.FACILITY ®2. PROPERTY OWNER ❑3.TANK OWNER 4u. <br /> VII.APPLICANT SIGNATURE <br /> Certification: I certify that the fomwtion provided herein is true and accurate to the ben of my knowledge. <br /> SIGNATURE APPLICANT DATE 4N. PHONE ass. <br /> /.2 -/a_,M <br /> (209)478-6as7 <br /> NAME OF APPLICANT(print) 410. TITLE OF APPLICANT 427. <br /> Amarjit S.Rai Owner/Operator <br /> STATE UST FACILITY NUMBER(Agmq..Wy) 46/ 1998 UPGRADE CERTIFICATE NUMBER(Aprr,w4 only) 429. <br /> (See Data Element 1,show. <br /> UPCF Hwfwrc-&(1/99)-1/2 www.unidoes.org Rev.02/16/00 <br />